A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?
Pelvic pain
Hematuria
A localized area of breast tenderness
A moderate amount of dark red lochia with a foul odor
The Correct Answer is A
Choice a) reason: Pelvic pain is a common symptom of endometritis. The pain is typically located in the lower abdomen and may be associated with uterine tenderness upon physical examination. This symptom, especially when combined with other signs such as fever and foul-smelling lochia, strongly suggests the need for further evaluation for endometritis.
Choice b) reason: Hematuria, or blood in the urine, is not a typical symptom of endometritis. While it could be a sign of other postpartum complications, such as urinary tract infections or bladder injury during childbirth, it does not directly indicate endometritis.
Choice c) reason: A localized area of breast tenderness is more indicative of a breast infection, such as mastitis, especially if associated with breastfeeding. It is not a symptom of endometritis, which affects the uterus and not the breasts.
Choice d) reason: While foul-smelling lochia can be a sign of endometritis, the key is the presence of a foul odor. A moderate amount of dark red lochia alone, without a foul odor, is a normal finding in the immediate postpartum period. It's the transition from rubra (red) to serosa (pink/brown) to alba (yellow/white) that is expected as the uterus heals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Nausea can be a common side effect of many medications and does not necessarily indicate toxicity. While it can be uncomfortable for the patient, nausea alone, without other symptoms, is not typically a sign of magnesium sulfate toxicity.
Choice B reason:
Drowsiness is another side effect that can occur with various medications and medical conditions. It may be a symptom of magnesium sulfate toxicity, especially if it is severe or combined with other symptoms, but on its own, it is not a definitive indicator of toxicity.
Choice C reason:
Facial flushing can be a reaction to medication, including magnesium sulfate, and may occur even at therapeutic levels. It is not usually a sign of toxicity unless accompanied by more serious symptoms.
Choice D reason:
Respiratory depression is a serious and potentially life-threatening condition that can indicate magnesium sulfate toxicity. It is characterized by a decrease in the ability to breathe and a drop in oxygen levels. This is a critical finding that requires immediate medical attention and intervention.
Correct Answer is A
Explanation
Choice a reason:
Hydration is crucial during pregnancy, especially for those with preeclampsia. Adequate water intake helps maintain blood volume and reduce blood viscosity, which can help manage blood pressure levels. Drinking 48 to 64 ounces of water daily is recommended to support the increased blood volume needed during pregnancy and to help prevent dehydration, which can exacerbate preeclampsia symptoms.
Choice b reason:
While reducing salt intake can be beneficial for managing blood pressure, it is not necessary to completely avoid salting foods during cooking. Instead, moderation is key. Excessive salt can lead to water retention, which can worsen preeclampsia, but some salt is needed for electrolyte balance and proper body function.
Choice c reason:
Protein is an essential nutrient for fetal growth and the repair and maintenance of maternal tissues. A daily intake of 40 to 50 grams of protein is generally recommended during pregnancy. However, for those with preeclampsia, protein needs may be higher due to potential protein loss in the urine. It's important to monitor protein intake and adjust as needed under medical guidance.
Choice d reason:
Limiting the intake of whole grains, raw fruits, and vegetables is not recommended. These foods provide essential nutrients, fiber, and antioxidants that are beneficial for both maternal and fetal health. They should be included as part of a balanced diet unless there are specific dietary restrictions advised by a healthcare provider.
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